Loss of patients in clinical trials that measure long-term survival following myocardial infarction

Loss of patients from clinical trials can nullify adequate randomization if the loss is unequally distributed among treatment groups. This study was designed to assess the magnitude of the problem in randomized control trials evaluating long-term therapy for survivors of myocardial infarction (MI). Only 19 of 52 trials reported having an explicit policy on withdrawals in the design stage; only 2 reported blinding the decision for withdrawal and only 7 reported accounting for withdrawals in sizing. In addition, only 16 gave the reader enough information to calculate the effect of withdrawals on trial results. In 2 of these 16 trials a p less than 0.05 result obtained by including withdrawals (intention to treat method) was reduced to p less than 0.05 when withdrawals were excluded. It is evident that many long-term trials do not contain adequate data on withdrawals. Readers of published trials are seldom able to judge whether or not withdrawals might affect the final results.

A new projective test: the Caine-Marteau-Dympna Test (CMD)

The Caine-Marteau-Dympna (CMD) Test, a new thematic apperception projective test, has acceptable inter-rater reliability. Validity was demonstrated by its ability to differentiate psychiatric in-patients from out-patients and non-patients, and by the relationships found between ratings derived from the test protocols and various questionnaires. These latter provide measures associated with either an inner or outer orientation towards the world. This has implications for many different areas of life, including occupational preference and adjustment, psychiatric symptom formation, psychological treatment expectancies and therapeutic outcome. Thus, the inner oriented individual, who is likely to be responsive to interpretative psychotherapy, tends to produce CMD responses displaying individualistic, abstract themes; a concern with intrapsychic conflict, deficiencies in social interaction and lack of structure; and internal control.

Lipopolysaccharide alteration is associated with induced resistance of Neisseria gonorrhoeae to killing by human serum

On SDS-PAGE, solubilized and proteinase K treated preparations of Neisseria gonorrhoeae strain BS4 (agar) showed differences in silver stained lipopolysaccharide (LPS) patterns, before and after induction to resistance to serum killing by incubation for 3 h at 37 degrees C with low Mr fractions from lysates of guinea pig red blood cells. Preparations from the original serum susceptible gonococci and LPS purified from such bacteria showed two components, but the preparations from the serum resistant gonococci were deficient in the higher Mr component. Furthermore, on immunoblotting with fresh human serum (FHS), the two LPS components of the susceptible gonococci reacted strongly with IgM. With preparations from the serum resistant gonococci there was no reaction in the area corresponding to the higher Mr component and a weaker reaction with the component of low Mr. Purified LPS from the susceptible gonococci neutralized the bactericidal activity of FHS against N. gonorrhoeae strain BS4 (agar) probably by reacting with the relevant antibody, since heated FHS was no longer bactericidal when mixed with a source of complement (human placental serum) after prior reaction with the LPS. These neutralization tests coupled with the results of immunoblotting strongly suggest that increased serum resistance is due to the lack of the high Mr LPS moiety.

Selection and optimisation of monoclonal antibodies for a two-site immunoradiometric assay for ACTH

Four monoclonal antibodies with predominant specificities towards different sequences within the ACTH molecule were investigated in a 2-site immunoradiometric assay (IRMA) for human ACTH. Antibody 3H9 recognises the extreme N-terminal sequence, antibodies 1A12 and 1D1 are specific for the mid N-terminal sequence but differ in that the former cross-reacts with alpha MSH whereas the latter does not, and antibody 2A3 recognises the C-terminal sequence. Combinations of iodinated antibodies with antibodies covalently linked to Sephacryl S300 were tested for their compatibility and potential for a sensitive assay. Two antibody combinations (1D1 plus 3H9 or 1A12) gave no dose-response curve indicating severe steric inhibition, whereas other combinations yielded assays with widely different detection limits (2-2400 ng ACTH/l). The combination of labelled 1D1 and solid-phase 2A3 gave the most sensitive assay and when optimised for antibody concentrations and incubation times the working range was 10-5 X 10(4) ng/l (CV less than 20%). The optimised sequential 2-step IRMA involves incubation of standard or test sample with labelled 1D1 for 18 h at 4 degrees C followed by incubation with solid-phase 2A3 for 2 h at room temperature, after which the labelled complex is separated by the sucrose layering technique. The detection limit of this IRMA was several 100-fold lower than by RIA using the same antibodies. The IRMA detected large molecular weight precursors containing the full ACTH sequence (22 000, 31 000 and 34 000) but not ACTH fragments (1-18, 1-24, 18-39). It is concluded that selected monoclonal antibodies provide a sensitive and rapid 2-site IRMA for intact ACTH and its precursors.

The effects of drugs on leucocyte changes following the injection of antigen into the peritoneal cavities of actively sensitised rats

The injection of antigen into the peritoneal cavities of actively sensitised rats produced an immediate reaction characterised by an increase in concentrations in the peritoneal fluids, collected 5 min later, of extravasated dye labelled plasma proteins, histamine and slow reacting substance of anaphylaxis (SRS-A). Changes were also produced in the numbers of leucocytes in the blood and peritoneal cavity. 5 min after antigen challenge there was a reduction in the number of cells that could be washed from the peritoneal cavity. 4 h after antigen there was an increase in numbers of neutrophils both in the blood and peritoneal washings and these fell to the levels in control rats at 24 h. 24 h after antigen, and continuing for 72 h, there was an increase in numbers of eosinophils and mononuclear cells in the peritoneal washings. The rats were injected intravenously with sephadex particles to produce a blood eosinophilia at the time of antigen challenge, this increased the numbers of eosinophils migrating into the peritoneal cavity but had no effect on antibody levels, the numbers of other leucocytes or on the immediate reaction. An inhibitor of lipoxygenase and cyclo-oxygenase metabolism of arachidonic acid, phenidone, at 100 mg/kg p.o., inhibited SRS-A release to control levels, in the immediate reaction, but had no effect on the leucocyte changes. The glucocorticosteroid, dexamethasone, at doses of 0.1 and 1 mg/kg p.o., produced little inhibition of SRS-A release but significantly inhibited neutrophil, eosinophil and mononuclear cell infiltration into the peritoneal cavity.(ABSTRACT TRUNCATED AT 250 WORDS)

Severity of fever in influenza: differential pyrogenicity in ferrets exhibited by H1N1 and H3N2 strains of differing virulence

Intracardial inoculation of large quantities (200 micrograms viral protein/kg body weight) of infectious or u.v.-inactivated purified influenza viruses into ferrets resulted in a rapid febrile response which was significantly lower for two recently isolated H1N1 viruses, A/USSR/90/77 and A/Fiji/15899/83, than for two virulent clones, 7a and 64c, of the A/Puerto Rico/8/34-A/England/939/69 (H3N2) reassortant virus system. These results, which are in accord with the severity of fever produced by these strains in intranasally infected ferrets, show that influenza virus strains can differ in their capacity to induce fever (probably reflecting a differential capacity to induce endogenous pyrogen from phagocytes) and indicate, since u.v.-inactivated strains are pyrogenic, that this may be due to differences between strains in the nature or amount of certain virion components.

Radial keratotomy and glare effects on contrast sensitivity

After radial keratotomy (RK) to correct myopia, some patients complain of 'glare'. Effects of a glare source on contrast sensitivity were measured in fifteen patients after unilateral RK. With each eye, determinations were made of the contrast required for detection of steady gratings (spatial frequencies of 0.7 and 2.9 cycles/deg), and for detection of flicker (unpatterned field flickering at rates of 8, 16, and 32 Hz). Grating or flicker was presented on a centrally fixated 4 deg test target (34 cd/m2 mean luminance), surrounded by a diffuse glare source (1700 cd/m2 mean luminance). For each stimulus, contrast thresholds were determined with glare-source off and with glare-source on. 'Glare loss' was defined as the decrement in contrast sensitivity measured with the glare source on. Significant findings were: (1) Both eyes showed glare losses for detection of gratings and for detection of flicker; (2) Spectacle lenses increased glare losses both for gratings and for flicker; (3) The RK eye showed a larger glare loss for flicker than the unoperated eye, but a smaller glare-loss for gratings; (4) For both flicker and gratings, glare loss tended to be greater in the RK eye, compared to the unoperated eye, in subjects who had larger pupil diameters in the testing situation; (5) The psychophysical measurements obtained in this study were not significantly correlated either with a questionnaire index of glare complaints or with the score obtained with the Miller-Nadler GlareTester.

Airway hyper-reactivity and blood, lung and airway eosinophilia in rats treated with Sephadex particles

The intravenous injection of Sephadex particles (G200) into rats produced a specific increase in numbers of blood eosinophils peaking 7 days later. A second injection, given on day 14 when the numbers of blood eosinophils had fallen to control levels, produced a dose-dependent increase in numbers, greater than the first, and peaking 5 days later. At this time there was a dose-dependent increase in numbers of eosinophils, but not of other leucocytes, in broncho-alveolar lavage fluids and lung tissue, together with an increase in sensitivity of the rats to the respiratory effect produced by the intravenous injection of 5-hydroxytryptamine.

Impact of associated medical conditions on clinical features of gout

In view of the various available drugs, we are now in a very much better situation for treatment of gout, with and without associated medical conditions. When several drugs are employed in one single patient, however, one may run into drug interactions, resulting into exaggerated hyperuricemia or induced acute gouty arthritis. In lieu of the various associated medical conditions, controlled or uncontrolled, the clinical features of gout may be modified. Accordingly, one must treat the patient's gout as well as his various stages of the associated medical conditions, and each patient must be individualized.

Effect of drugs on the increase in cell numbers in the peritoneal cavity of the actively sensitised mouse after intraperitoneal challenge with antigen

The injection of antigen into the peritoneal cavity of actively sensitised mice produced an increase in the number of neutrophils in peritoneal washings collected 4 h later but after 1 day the numbers had returned to control levels. The increase in numbers of mononuclear cells and eosinophils in the peritoneal washings peaked at 2 days and persisted for at least 5 days. Dosing the mice with phenidone, a dual inhibitor of the cyclo-oxygenase and lipoxygenase pathways of arachidonic acid metabolism, potentiated the neutrophil infiltration at 4 h but had no significant effect upon the subsequent mononuclear cell and eosinophil infiltration. In contrast, treatment with the corticosteroid, dexamethasone, reduced the infiltration by all three types of cells, providing further evidence that the corticosteroids can inhibit immune-induced cellular infiltrations by mechanisms other than the inhibition of arachidonic acid metabolism. Isoprenaline, given to the mice before antigen challenge, had no effect on the subsequent neutrophil infiltration, but repeated doses did inhibit the mononuclear cell and eosinophil infiltration measured 4 days later. Aminophylline, disodium cromoglycate and cyproheptadine had no effect upon the cellular changes.

Extraintestinal cancers in inflammatory bowel disease

The case histories of 1961 patients with inflammatory bowel disease (IBD), 1227 with Crohn's disease (CD) and 734 with ulcerative colitis (UC), have been studied for the incidence of extraintestinal malignant neoplasms. There were 54 extraintestinal cancers in 51 patients: 28 patients with CD and 23 with UC; 25 men and 26 women. There were 9 breast, 7 skin, 15 reticuloendothelial, 11 genitourinary, 3 lung, 3 perianal, 2 pancreatic islet cell, and several miscellaneous cancers. The number of patient-years from the onset of disease to the last date of follow-up was calculated for men and women with each form of IBD. The observed number (O) of neoplasms was recorded. The expected number (E) of neoplasms was derived from the Department of Health, Education, and Welfare (DHEW) incidence figures for the same neoplasms that occurred in a standard age- and sex-matched population. The O/E ratio was then calculated for each type of cancer as well as for the entire series. There were no statistically significant increases in overall O/E ratios of extraintestinal cancers for either CD (0.76) or UC (1.32). On the other hand, several specific types of cancer did appear to occur with a frequency that was significantly greater than expected. These cancers were classified into two groups. The first group included reticuloendothelial neoplasms. There was an excess of leukemias in UC (P less than 0.005) and an excess of lymphomas in both UC and CD (P less than 0.005). The second group included three squamous cell cancers of the perianal region, an incidence 30 times greater than expected, and two squamous cell cancers of the vagina, also in excess of the expected number. Lymphoma, leukemia, and squamous cell cancers have been reported to occur in excess in immunosuppressed or irradiated patients. It may therefore be speculated that the apparently increased incidence of these neoplasms in the patients with ileitis and colitis might be related to immunologic deficiencies associated with IBD, to the long-term administration of steroids or other immunosuppressive medications that were given to most of the patients or, possibly, to increased exposure to ionizing radiation. The apparently increased incidence of perianal and vaginal cancers of the squamous variety might be a consequence of the combined effects of chronic inflammatory disease involving these areas and primary immune suppression.

Extraintestinal cancers in inflammatory bowel disease

The case histories of 1961 patients with inflammatory bowel disease (IBD), 1227 with Crohn's disease (CD) and 734 with ulcerative colitis (UC), have been studied for the incidence of extraintestinal malignant neoplasms. There were 54 extraintestinal cancers in 51 patients: 28 patients with CD and 23 with UC; 25 men and 26 women. There were 9 breast, 7 skin, 15 reticuloendothelial, 11 genitourinary, 3 lung, 3 perianal, 2 pancreatic islet cell, and several miscellaneous cancers. The number of patient-years from the onset of disease to the last date of follow-up was calculated for men and women with each form of IBD. The observed number (O) of neoplasms was recorded. The expected number (E) of neoplasms was derived from the Department of Health, Education, and Welfare (DHEW) incidence figures for the same neoplasms that occurred in a standard age- and sex-matched population. The O/E ratio was then calculated for each type of cancer as well as for the entire series. There were no statistically significant increases in overall O/E ratios of extraintestinal cancers for either CD (0.76) or UC (1.32). On the other hand, several specific types of cancer did appear to occur with a frequency that was significantly greater than expected. These cancers were classified into two groups. The first group included reticuloendothelial neoplasms. There was an excess of leukemias in UC (P less than 0.005) and an excess of lymphomas in both UC and CD (P less than 0.005). The second group included three squamous cell cancers of the perianal region, an incidence 30 times greater than expected, and two squamous cell cancers of the vagina, also in excess of the expected number. Lymphoma, leukemia, and squamous cell cancers have been reported to occur in excess in immunosuppressed or irradiated patients. It may therefore be speculated that the apparently increased incidence of these neoplasms in the patients with ileitis and colitis might be related to immunologic deficiencies associated with IBD, to the long-term administration of steroids or other immunosuppressive medications that were given to most of the patients or, possibly, to increased exposure to ionizing radiation. The apparently increased incidence of perianal and vaginal cancers of the squamous variety might be a consequence of the combined effects of chronic inflammatory disease involving these areas and primary immune suppression.

Extraintestinal cancers in inflammatory bowel disease

The case histories of 1961 patients with inflammatory bowel disease (IBD), 1227 with Crohn's disease (CD) and 734 with ulcerative colitis (UC), have been studied for the incidence of extraintestinal malignant neoplasms. There were 54 extraintestinal cancers in 51 patients: 28 patients with CD and 23 with UC; 25 men and 26 women. There were 9 breast, 7 skin, 15 reticuloendothelial, 11 genitourinary, 3 lung, 3 perianal, 2 pancreatic islet cell, and several miscellaneous cancers. The number of patient-years from the onset of disease to the last date of follow-up was calculated for men and women with each form of IBD. The observed number (O) of neoplasms was recorded. The expected number (E) of neoplasms was derived from the Department of Health, Education, and Welfare (DHEW) incidence figures for the same neoplasms that occurred in a standard age- and sex-matched population. The O/E ratio was then calculated for each type of cancer as well as for the entire series. There were no statistically significant increases in overall O/E ratios of extraintestinal cancers for either CD (0.76) or UC (1.32). On the other hand, several specific types of cancer did appear to occur with a frequency that was significantly greater than expected. These cancers were classified into two groups. The first group included reticuloendothelial neoplasms. There was an excess of leukemias in UC (P less than 0.005) and an excess of lymphomas in both UC and CD (P less than 0.005). The second group included three squamous cell cancers of the perianal region, an incidence 30 times greater than expected, and two squamous cell cancers of the vagina, also in excess of the expected number. Lymphoma, leukemia, and squamous cell cancers have been reported to occur in excess in immunosuppressed or irradiated patients. It may therefore be speculated that the apparently increased incidence of these neoplasms in the patients with ileitis and colitis might be related to immunologic deficiencies associated with IBD, to the long-term administration of steroids or other immunosuppressive medications that were given to most of the patients or, possibly, to increased exposure to ionizing radiation. The apparently increased incidence of perianal and vaginal cancers of the squamous variety might be a consequence of the combined effects of chronic inflammatory disease involving these areas and primary immune suppression.

Medical care for the poor: finite resources, infinite need

Health care in this nation is becoming multitiered--with the poor in jeopardy of being excluded from even minimal care--because of the mistaken belief that money can buy unlimited health care for everyone. But our medical resources are finite, and choices must be made on how to distribute those resources. These choices should be based on a carefully reasoned concept of distributive justice; but even more important, they should be rooted in a Christian sense of community and in the conviction that service to others is more important than life itself. At least three basic models of justice can be identified. Market justice follows the general rule, To each according to his or her ability to pay. Merit justice holds that medical care should be apportioned relative to patients' efforts to stay healthy. Needs-based justice maintains that individuals' needs should be the sole criterion for allocating health care. Developing and testing such concepts of justice is necessary, but it is not enough. As those with economic and social power increasingly capture society's medical resources to keep their own deaths at bay through costly and extraordinary forms of treatment, Christians may well be impelled to take a stand in behalf of those who are being deprived of basic care. This stand may even include forgoing extraordinary treatment for themselves and accepting the appropriateness of their own deaths. Such a witness to the world, however, must be founded in faith and in Christian belief regarding the meaning of death.

Effect of avoparcin interaction with anticoccidial compounds on the growth and carcase composition of broilers

The anticoccidial drugs narasin, lasalocid, monensin and salinomycin, with and without avoparcin, were fed to 1280 broiler chickens from 1 to 49 d old. At day 49 significant interactions were detected between avoparcin and the anticoccidial compounds for body weight and food consumption. This indicated that the increases in body weight and food consumption obtained with avoparcin were greater with some anticoccidial compounds (lasalocid and salinomycin for body weights and lasalocid for food consumption) than with others (monensin and narasin for body weights and monensin, narasin and salinomycin for food consumption). Overall there was evidence that avoparcin increased body weight (5.8%), food consumption (2.5%) and efficiency of food utilisation (2.9%). In addition avoparcin produced significant increases in plucked weight and the proportion of visceral fat together with and decreases in the proportions of edible giblets and waste offal.

Transformation in Bacillus subtilis: further characterization of a 75,000-dalton protein complex involved in binding and entry of donor DNA

A 75,000-dalton protein complex purified from membranes of competent Bacillus subtilis cells was previously shown to be involved in both binding and entry of donor DNA during transformation. The complex, consisting of two polypeptides, a and b, in approximately equal amounts, showed strong DNA binding as well as nuclease activity (H. Smith, K. Wiersma, S. Bron, and G. Venema, J. Bacteriol. 156:101-108, 1983). In the present experiments, peptide mapping indicated that the two polypeptides are not related. Chromatography on benzoylated, naphthoylated DEAE-cellulose showed that polypeptide b generated single-stranded regions in double-stranded DNA. A considerable amount of the DNA was rendered acid soluble by polypeptide b. The nuclease activity of polypeptide b was reduced in the presence of polypeptide a. This resulted in an increased fraction of high-molecular-weight double-stranded DNA containing single-stranded regions. The acid-soluble DNA degradation products formed by polypeptide b consisted exclusively of oligonucleotides. In contrast to its nuclease activity, which was specifically directed toward double-stranded DNA, the DNA binding of the native 75,000-dalton complex to single-stranded DNA was at least as efficient as to double-stranded DNA.

Recent H1N1 viruses (A/USSR/90/77, A/Fiji/15899/83, A/Firenze/13/83) replicate poorly in ferret bronchial epithelium. Brief report

Three recent wild-type H1N1 influenza virus isolates (A/USSR/90/77, A/Fiji/15899/83 and A/Firenze/13/83) replicated poorly in organ cultures of ferret bronchial tissue compared with the replication of an H3N2 wild-type virus (A/England/939/69). All four viruses replicated well in nasal turbinate tissue. Examination of one H1N1 virus (A/USSR/90/77) in vivo showed heavy infection in the upper respiratory tract of ferrets but little in the lower respiratory tract. These results raise the possibility that the mildness of human influenza arising from the H1N1 strains may be due to lack of capacity to attack the lower respiratory tract as well as the presence of antibody in previously exposed persons.